One of the most frequent questions I get asked these days is, “What impact will the presidential election have on health care?”
It is a difficult question to answer, because the answer depends not only upon who becomes our next president, but which party controls the U.S. Senate and House of Representatives and because the presidential candidates themselves have not provided as much detail on their positions as I would like.
Let’s start with the candidates’ positions as we know them. The contrasts are stark. Hillary Clinton wants to build upon the Affordable Care Act; Donald Trump wants to repeal and replace the law.
Clinton wants to increase the enrollment in exchange health plans and to do so would offer additional tax credits to help make these plans more affordable. She also wants to address those markets that do not have a sufficient number of health plans offering products on the exchange to create competition by introducing a “public option,” i.e., a government-run program such as Medicare. (Clinton has long advocated for a public option buy-in that would allow all Americans between the ages of 55 and 64 to purchase coverage through Medicare.) Clinton and Trump have both supported granting Medicare the authority to negotiate drug prices and Americans the right to purchase medications from abroad to counter rising pharmaceutical costs.
An analysis by RAND Health concluded that Clinton’s proposals would result in the insuring of an additional 9.6 million Americans as early as 2018, cutting the uninsured rate by 39 percent. If all of her proposals were enacted, total out-of-pocket healthcare spending would decrease to $421 to $2,500 per person, depending upon income level, compared with an average out-of-pocket cost of $3,200 today under the ACA. The federal deficit would increase by a projected $88.5 billion if all of her reforms were enacted.
Trump’s policy proposals are a bit vaguer. Following repeal of the ACA, Trump supports a plan to make individual health insurance fully tax-deductible to promote individuals to purchase their own insurance outside of the marketplaces created under the ACA. He also wants to encourage the use of health savings accounts. He would promote competition among insurance companies by permitting them to sell coverage across state lines. While Clinton wants to encourage more Medicaid expansion through the ACA, Trump wants to eliminate the per-person funding of Medicaid and instead have the federal government issue block grants to the states and allow the states to manage their own Medicaid programs.
That same RAND Health analysis concluded that Trump’s proposals would result in 19.7 million (with a range of 16 million to 25 million) Americans losing their health insurance by 2018, essentially reversing all of the gains made under the ACA. In addition, the average out-of-pocket costs for those who purchase insurance on their own would increase (average out-of-pocket costs in the individual market are projected to be $4,700 per person under Trump’s plan, ranging between $3,500 and $5,700) and the federal deficit would increase by $5.8 billion if all his proposals were enacted, with a range of $0.5 billion to $41 billion if only one of his reforms were enacted.
The changes proposed by both candidates would require the enactment of legislation for implementation.
If the bitter partisanship of the past is a predictor of the future, neither candidate will accomplish much if the other party maintains control of the U.S. Senate and House. However, in the event the party in the White House is the same as the party in control of Congress, we could see major changes that will affect health care for years to come.
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.